The first case study was done on a 76-year-old male who was admitted to the hospital with ammonia. The physician who was creating the physical and history on this patient noticed that the patient was admitted to the hospital about six months ago with the same issue. So, when creating the History and Physical (H&P) for this visit the provider copied some information from the prior visit and pasted it into the new note. One of the lines that were captured was that the patient had hypertension, diabetes type 2, and a urinary tract infection (UTI). As the patient was treated throughout the visit and was eventually discharged the coding departed received the documentation for this visit with the new diagnosis of pneumonia, hypertension, diabetes type 2 and a urinary tract infection (UTI). The coding outcome was of this account was a DRG of 194 and a reimbursement of $4,069 dollars. The issue was that the urinary tract infection (UTI) from the prior visit was not an issue on the former visit and coding for the diagnosis resulted in a complications or comorbidity (CC) however removal of the UTI changes the DRG to 195 simple pneumonia and pleurisy without a complication (CC) and the reimbursement dropped by over a thousand dollars to $2, 959. This is an example where leaving in information in this case of a prior diagnosis isn’t implacable to the current visit had an impact on the coding and resulted in overpayment.
CASE STUDY 2
The second case study was done on a 63 year old woman admitted in the morning to a hospital for congestive heart failure (CHF. Upon admission some additional lab test were done one of which showed that the patient had a potassium level of 5.1 and the normal range for potassium is from 3.7 to 5.2. In creating the documentation for this visit specifically the history and physical note the admitting physician notices that the patient had some prior admissions due to her congestive heart failure (CHF), copied some context from the prior visit notes, pasted it into the current history and physical (H&P) in order to speed up the creation of the note. In doing so one of the items that was captured was the patient’s potassium level in admission for a prior visit. On the prior visit the patient’s potassium level was to 2.9, which is below the normal range and in copying that information forward and not editing it made it appear as if the patients potassium level in the current visit was 2.9. Thus, moving forward to the evening shift new hospital staff arrive to cover this patient. The evening shift hospitalist reads the history & physical (H&P), for the new admission and notes that the potassium level is low at 2.9. This hospitalist then ordered potassium supplements and a recheck for the potassium levels for the next day. The issue in this case study is the mix match potassium levels because the patient was actually within the normal range however the documentation made it appear as if the patients potassium level was low. Two issues arise from these encounters and the most important one is an adverse event risk because administering potassium supplements to a patient with normal potassium levels can have a devastating impact on the patient. The second is avoidable cost ordering a re-check of the potassium level is an additional cost that could have been prevented. So, here there is a second instance of copy-paste being used in the electronic health record (EHR) and in many instances no issues would have occurred but now we have just one bit of information that proves that copy forward can have some adverse event risks for this patients encounter.
SPELLING ERRORS IN CLINICAL DOCUMENTATION
Accurate medical documentation is critical for safe patient care and effective inter-provider communication. Medical documentation errors can lead to some causes in injury and or even patient deaths, and is also important for the care correlation between providers. Studies show that about 5 million errors per year are tied to wrong documentation involving drugs that look and sound alike such as; Altenol vs. Alendol or Lyrica vs. Lamictal. These spelling errors can happen due to non-word errors such as; Humulog for Humalog and are commonly due to free-text entries (typed notes) or real-word errors (words spelled correctly but are contextually wrong, such as; (there for or their) Speech Recognition (SR) generated text. Studies used sources including a couple of standard medical terminology such as; UMLS, SNOMED, CT, RxNorm and Cetera. The error correction was based on Shannon’s noisy channel model; specifically using the Daneray-Levenshtein edit distance between misspellings and the suggestions, both in terms of their orthography and phonetics. To evaluate and compare their systems performance, they used ASpell Default setting as their baseline. It is an open, free software spell checker, which helped to show a significant improvement in the spell check regarding precision, and accuracy. Although, speech recognition technology has been widely used in medical practices, the quality and accuracy of clinical documents hasn’t been thoroughly studied or reported. The limited scope and sample size, for the study used a discharge summary and a progress note, and another involved two physicians dictating 47 emergency department charts. The reported error rates varied from 1.5 percent to 15.25 words with a much higher error rate observed in a more recent larger study in radiology reports. The reviews done by “SM Error Rate,” were measured by the length of time it takes to dictate a note, and the error rates due to the number of errors divided by the number of words, percentage of each error type. Many physicians and even medical students have been in the practice of creating they’re not in the room with the patient. The advantage is that who is the world’s expert on how the patient is feeling? It is the patient! So, if the provider documents something that is not correct, the patient is there to correct it. Today, we are moving toward greater involvement of patients in participation of their own notes and has great potential when it comes to the error ratio and help to summarize voluminous records in a way that other people caring for the patient can then read and understand.
DOWN TIME SYSTEM FAILURES
If there is one thing in medicine a human can count on is the unexpected even though most of their training is to expect the unanticipated. When health care providers are working in a electronic health care (EHR) environment they get used experiencing downtime normally from their electronic health care records system (EHRs). Sometimes downtime is related to an issue with the database but most providers are trained to handle that. Although, sometimes providers encounter unusual circumstances that can make a system unavailable because the application was broken caused by the server failure during the backup process. Many errors can occur while in the downtime hours and capturing data poses problems. Most providers never anticipate that a backup process could fail but it can and does. To key to avoiding errors while in downtime status is to be prepared but electronic health records (EHR) implementation presents a new set of
challenges. Systems that run perfectly in demos, in realty sometimes do not. Providers have to change how they work in order to use electronic health records (EHRs) well, because it is inefficient to simply put an electronic health record (EHR) on top of an existing routine. Electronic Health Records (EHRs) introduce the potential for safety risks in ways we haven’t been trained to anticipate.
MEDICAL PROFESSIONAL LIABILITY
The most human errors and liabilities made are often made when using electronic medical records (EMRs). In order to avoid some of these specific errors and liabilities in the future the understanding that they are user friendly, and more efficient is sometimes overestimated. However, with the entire drop down boxes and check lists clinicians should be users should be careful to make sure that the information input is completely accurate so that the systems captures any situation which could pose a danger to the patient at that time. In fact, if none of the drop-downs is does not exactly portray what the user is seeing they should continue with free texting to be sure that the EMR captures exactly what the medical condition is. One other new issue that is on the rise is the way that humans in medicine communicate now is so often not only by email but by text, even some physicians are doing this with their patients and this should obviously be avoided because it runs the risk of medical liability due to misinterpretations. However, emails are fine to use as long as they’re within the system. For example; some charting systems utilize email servers that allow communication that is set-up with their physician but captured within the system so that emails are preserved and a record of
them can be kept. In fact, emailing back and forth with patients should be avoided at all costs because there is no way to really maintain a complete record of the communications with the patients.
REDUCING HUMAN ERRORS IN EHRs
Each of these theoretical positions makes an important contribution to our understanding of the importance of reducing human errors in Electronic Health Records (EHRs). First, providers should re-engineer their templates to prevent the needless replication of items. In addition to duplication data providers should develop a “Medical History (H&P),” and examination information that can be reviewed, reused, amended and improve the problem list functions to serve as an alternative to the systems copy test list values. In short, cautioning clinical departments of the implications against excessive use of the copying and pasting in the effort of boosting productivity. It is important however to overemphasis by teaching practitioners and students to adopt polices put in place that prevent unethical and unacceptable practices that pose major risk to providers and their practice. “Computer systems need to better account for potential error said Shawna Perry an associate professor says that compute systems need to better account the risks of human error that stem from the culture of a department, which might be fast pace and hectic because it only amplifies the risks of human errors using Electronic Health Records (EHRs). Another key point is the prevention of data integrity failures that humans have some control over such as: using a computer interface that is always visible, readable, understandable, and is clear and concise. The system user should make sure that their computer displays all patient information clearly on the screen at on one occasion, and the number of records should only be displayed one at a time. Most important is to require patients to show legal forms of identification at check in an various points of their care process. Frequently, minimize free-text entry orders and limit interruptions from high alert risks or excessive priority conditions. Always run updates, upgrades to the system and support event-reporting methods that identifies and address IT system problems. The most compelling evidence significantly supports that providers who provide comprehensive training to their healthcare IT system users have the best outcomes.